Citation Nr: 0000366 Decision Date: 01/06/00 Archive Date: 01/11/00 DOCKET NO. 98-05 419 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Albuquerque, New Mexico THE ISSUES 1. Entitlement to service connection for gastric ulcer disease. 2. Entitlement to service connection for chronic organic disability of the hands, fingers, elbows, and shoulders. REPRESENTATION Appellant represented by: Veterans of Foreign Wars of the United States ATTORNEY FOR THE BOARD Artur F. Korniluk, Associate Counsel INTRODUCTION The veteran had active military service from June 1976 to May 1997. This matter comes to the Board of Veterans' Appeals (Board) from the Department of Veterans Affairs (VA) Albuquerque Regional Office (RO) November 1997 rating decision which denied service connection for ulcers and arthralgia of the hands, fingers, elbows, and shoulders. FINDINGS OF FACT 1. A bleeding gastric ulcer was treated during service, but it appears to have healed without residual disability or recurrent symptomatology prior to service separation; gastric ulcer disease or symptoms associated therewith were not diagnosed on service retirement medical examination or at any time thereafter. 2. There is no current medical diagnosis of chronic organic disability involving the hands, fingers, elbows, or shoulders (other than left ulnar styloid epiphysis), and competent medical evidence does not show that any such claimed disability is linked to active service, any incident occurring therein, or episodes of pain, itching, and/or swelling of the hands and elbows treated in service, or right shoulder pain reported on medical examination prior to service retirement. 3. There is a current medical diagnosis of left ulnar styloid epiphysis which is likely to have had its onset during the veteran's active service. CONCLUSIONS OF LAW 1. The veteran has not presented a well-grounded claim of service connection for gastric ulcer disease. 38 U.S.C.A. § 5107(a) (West 1991). 2. The veteran has not presented a well-grounded claim of service connection for chronic organic disability of the hands, fingers, elbows, and shoulders (other than left ulnar styloid epiphysis). 38 U.S.C.A. § 5107(a) (West 1991). 3. The veteran's left ulnar styloid epiphysis was incurred during active service. 38 U.S.C.A. §§ 1110, 1131, 5107(b) (West 1991). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Service connection may be allowed for chronic disability, resulting from injury or disease, incurred in or aggravated by a veteran's period of active service. 38 U.S.C.A. §§ 1110, 1131. Service connection may also be allowed on a presumptive basis for arthritis and peptic ulcers if the pertinent disability becomes manifest to a compensable degree within one year after a veteran's separation from service. 38 U.S.C.A. §§ 1101, 1112, 1113, 1137 (West 1991); 38 C.F.R. §§ 3.307, 3.309 (1999). For a showing of chronic disease in service there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time, as distinguished from merely isolated findings or a diagnosis including the word chronic. Continuity of symptomatology is required when the condition noted during service is not, in fact, shown to be chronic or where the diagnosis of chronicity may be legitimately questioned. When the fact of chronicity in service is not adequately supported, a showing of continuity after discharge is required to support the claim. 38 C.F.R. § 3.303(b) (1999). The U.S. Court of Appeals for Veterans Claims (the Court) has held that lay observations of symptomatology are pertinent to the development of a claim of service connection, if corroborated by medical evidence. See Rhodes v. Brown, 4 Vet. App. 124, 126-127 (1993). The Court established the following rules with regard to claims addressing the issue of chronicity. Chronicity under the provisions of 38 C.F.R. § 3.303(b) is applicable where evidence, regardless of its date, shows that a veteran had a chronic condition in service and still has such condition. Such evidence must be medical unless it relates to a condition as to which, under applicable case law, lay observation is competent. If the chronicity provision is not applicable, a claim may still be well grounded if (1) the condition is observed during service, (2) continuity of symptomatology is demonstrated thereafter and (3) competent evidence relates the present condition to that symptomatology. Savage v. Gober, 10 Vet. App. 488, 495 (1997). A lay person is competent to testify only as to observable symptoms. A lay person is not, however, competent to provide evidence that the observable symptoms are manifestations of chronic pathology or diagnosed disability. Falzone v. Brown, 8 Vet. App. 398, 403 (1995). A determination of service connection requires a finding of the existence of a current disability and a determination of a relationship between the disability and an injury or disease incurred in service. Watson v. Brown, 4 Vet. App. 309, 314 (1994). However, service connection may be granted for a post-service initial diagnosis of a disease that is established as having been incurred in or aggravated by service. 38 C.F.R. § 3.303(d) (1999). The threshold question is whether the veteran has presented evidence that his claim is well grounded. See 38 U.S.C.A. § 5107(a). A well-grounded claim is a plausible claim. Murphy v. Derwinski, 1 Vet. App. 78, 81 (1990). A mere allegation that a disability is service connected is not sufficient; the veteran must submit evidence in support of his claim which would justify a belief by a fair and impartial individual that the claim is plausible. In order for a claim to be well grounded, there must be competent evidence of current disability (a medical diagnosis), of incurrence or aggravation of a disease or injury in service (lay or medical evidence), and of a nexus between the in- service injury or disease and a current disability (medical evidence). See Caluza v. Brown, 7 Vet. App. 498 (1995). Where the determinative issue involves a question of medical diagnosis or causation, competent medical evidence to the effect that the claim is plausible or possible is required to establish a well-grounded claim. Libertine v. Brown, 9 Vet. App. 521 (1996); Grottveit v. Brown, 5 Vet. App. 91, 93 (1993). A lay person is not competent to make a medical diagnosis or to relate a medical disorder to a specific cause. See Grivois v. Brown, 6 Vet. App. 136, 140 (1994), citing Espiritu v. Derwinski, 2 Vet. App. 492, 494 (1992). Therefore, lay statements regarding a medical diagnosis or causation do not constitute evidence sufficient to establish a well-grounded claim under 38 U.S.C.A. § 5107(a). See Grottveit, 5 Vet. App. at 93. The veteran's service medical records reveal a February 1980 report of occasional diarrhea and epigastric pain. On examination in April 1980, he indicated that he had occasional loose stools. A June 1987 computerized tomography study of the abdomen revealed no abnormality. On December 27, 1993, he was admitted to the emergency room with complaints of weakness, dizziness, and hematochezia. He was hospitalized for 3 days, during which a 1.5 centimeter (cm) antral gastric ulcer and duodenal bulb deformity were diagnosed. In January 1994, it was noted he had upper gastrointestinal bleed in December 1993 and was found to have a 1.5 cm gastric ulcer; on examination, he indicated that he was asymptomatic, and clinical assessment was "stable." In April 1994, it was reported that he was asymptomatic; upper gastrointestinal series revealed a normal gastric chamber, no evidence of a healing ulcer, a normal C-loop, and adequately distending duodenal bulb and proximal small bowel. On follow-up medical examination in June 1994, he was asymptomatic. On examination in February 1995, a history of bleeding gastric ulcer was noted. An undated clinical note indicates he had a gastric ulcer with gastrointestinal bleeding on December 28, 1994. On service retirement medical examination in October 1996, he reported a history of hospitalization due to a bleeding ulcer in 1994, but no abnormal finding was noted on clinical evaluation of his abdomen and viscera conducted in October 1996. Service medical records also reveal a May 1988 report of right hand and forearm swelling and decreased range of motion following an insect bite. In May 1990, the veteran reported right hand tenderness and itching due to an insect bite. On follow-up examination later in May 1990, it was noted that erythema and edema on the dorsum of the right hand were improving; on examination, there was moderate erythema, edema, and warmth of the right hand, and epitrochlear/axillary nodes were noted; a possible diagnosis of gout was indicated. On follow-up examination in May 1990, resolving cellulitis involving the dorsum of the right hand was diagnosed. In November 1991, he complained of right forearm rash, itching, and swelling due to an insect bite. In May 1993, he indicated that he experienced itching of the left wrist, noting that he was bitten by an insect 6 months earlier; on examination, pruritic papula on left wrist was diagnosed. In March 1994, he reported right elbow pain; on examination, there was evidence of right elbow edema without bruising, and the elbow was tender to palpation; the clinical assessment was tennis elbow. In February 1995, he reported elbow pain and stiffness; clinical assessment was left epicondylitis. On follow-up examination in March 1995, he indicated that he had bilateral elbow pain for a "long time;" on examination, there was no evidence of swelling, and range of motion was full; X-ray study of the elbows was normal; the clinical assessment was no orthopedic condition deserving any specific treatment. On service retirement medical examination in October 1996, he reported a history of rheumatism, frequent right shoulder pain, and intermittent tennis elbow, but no abnormal finding was identified on actual clinical evaluation of his upper extremities. On VA medical examination in August 1997, the veteran indicated he had diarrhea with black tarry stools during service in 1992-93, and that he was hospitalized in intensive care for 3 days with a diagnosis of 3 gastric ulcers (one of which was bleeding). He denied a history of epigastric pain, nausea, or vomiting, but indicated that he noticed black stools 3 or 4 times since 1993 (the last one 3 or 4 weeks prior to the examination). On examination, the abdomen was flat, soft and non-tender. Upper gastrointestinal series was normal. History of bleeding gastric ulcers, a history of recurrent melena, and "no evidence of bleeding at present" were diagnosed. On VA medical examination in August 1997, the veteran indicated he had morning stiffness in the hands and fingers for 7 years, and intermittent stiffness and aching in the shoulders and elbows. On examination, there was no evidence of deformity, swelling, tenderness, or impaired range of motion involving the wrists, hands, fingers, shoulders, or elbows. X-ray study of the hands revealed an ununited epiphysis of the ulnar styloid on the left, but the study was otherwise normal. History of intermittent arthralgia of the hands, fingers, elbows, and shoulder was diagnosed, and the examiner indicated "normal physical examination." Clinical records from the William Beaumont Army Medical Center (AMC) in September 1997 reveal a report of history bleeding ulcers in 1992, treated with Zantac, and arthritis involving the veteran's wrists. On examination, an unconfirmed diagnosis of ulcer disease was indicated. In December 1997, the veteran was evaluated at Beaumont AMC, seeking documentation of an active bleeding ulcer and arthralgia of the elbows. On examination and review of available clinical records, the physician indicated that the veteran had a gastric ulcer with gastrointestinal bleeding on December 28, 1994, and that he experienced lateral epicondyle pain in February 1995. The clinical assessment was, in pertinent part, "joint pains." Based on the foregoing, the Board believes that service connection for left ulnar styloid epiphysis is warranted. Although the service medical records do not show specific injury or trauma to the left wrist, and left ulnar styloid epiphysis was not diagnosed or specifically treated during active service, he indicated he developed recurrent pain and stiffness involving the left wrist in service (and was treated for left wrist itching following an insect bite in May 1993). Left ulnar styloid epiphysis was not evident, clinically, prior to his service entrance in 1976, but it was diagnosed shortly after service separation in May 1997 (see August 1997 VA medical examination report). Thus, resolving the benefit of any doubt in the veteran's favor, the Board finds that his current left ulnar styloid epiphysis developed during active service. 38 C.F.R. § 3.102 (1999). Regarding the claim of service connection for gastric ulcers, the Board finds that the claim is not well grounded. In particular, while service medical records reveal that gastric ulcer and gastrointestinal bleeding were diagnosed and treated (on an inpatient basis) during service in December 1993, the records show that the ulcer healed without any objectively demonstrable residual disability prior to service separation in May 1997. On several follow-up examinations after the December 1993 diagnosis and treatment of a bleeding gastric ulcer, it was indicated that he was asymptomatic. No contemporaneous symptoms or disability were diagnosed on service retirement medical examination in October 1996 (at which time a history of bleeding ulcers was indicated), and only a history of bleeding gastric ulcers was indicated on VA medical examination in August 1997. Most importantly, the veteran sought clinical documentation of an active gastric ulcer disease at Beaumont AMC in December 1997. Although past history of a bleeding ulcer was indicated at that time, a current disability was not diagnosed. Thus, as a current confirmed diagnosis of gastric ulcer disease is not supported by objective medical evidence, the veteran's claim must be denied as not well grounded. See Rabideau, 2 Vet. App. 14; see also Brammer v. Derwinski, 3 Vet. App. 223 (1992) (in the absence of proof of a present disability there can be no valid claim). The Board notes that on service retirement medical examination in October 1996, the veteran reported a history of a bleeding ulcer requiring hospitalization in 1994, that an undated clinical note in service documented that gastric ulcer was treated on December 28, 1994, and that the veteran's treating physician at the Beaumont AMC in December 1997, referred to history of gastric ulcer treatment on December 28, 1994. However, the entirety of the record shows that a bleeding gastric ulcer, requiring hospitalization, was diagnosed and treated in December 1993 rather than December 1994 (see e.g. the service medical records, the August 1997 VA medical examination report at which time the veteran reported hospitalization due to gastric ulcer in 1992-93; no reference has been made, by or on behalf of the veteran, with regard to hospitalization/bleeding gastric ulcer treatment on more than one occasion during service). With regard to the claimed disability involving the veteran's hands, fingers, elbows, and shoulders (with the exception of left ulnar styloid epiphysis), the Board finds that such claims are not well grounded. Although his service medical records reveal reports of pain, swelling, and itching of the hands (following insect bites) and elbows and shoulder pain (including diagnoses of right tennis elbow and left epicondylitis), chronic organic disability involving the hands, fingers, elbows, and/or shoulders was not diagnosed at the time of the 1996 service retirement medical examination or indeed at any time thereafter. The pertinent joints/extremities were examined by VA in August 1997, as discussed above, but no objective demonstrable abnormality was identified at that time (with the exception of left ulnar styloid epiphysis). Moreover, while the clinical assessment on evaluation at Beaumont AMC in December 1997 was "joint pains," (at which time pertinent medical history of in- service treatment was identified), chronic organic disability involving the hands, fingers, elbows, and shoulders were not diagnosed. Accordingly, as there is no current confirmed diagnosis of organic disability of the veteran's hands, fingers, elbows, and/or shoulders (with the exception of left ulnar styloid epiphysis), the claims must be denied as not well grounded. See Rabideau, 2 Vet. App. 14; see also Brammer, 3 Vet. App. 223 (in the absence of proof of a present disability there can be no valid claim). The Board is mindful of the veteran's contention that he currently has a gastric ulcer disease and chronic disability involving the hands, fingers, elbows, and/or shoulders (in addition to left ulnar styloid epiphysis), and that such disability is related to active service. While the credibility of his contention is not challenged and his competence to testify with regard to observable symptoms of recurrent pain in the pertinent joints and having black stools is noted, consistent with Cartright v. Derwinski, 2 Vet. App. 24 (1991), he is simply not competent, as a lay person, to render a medical diagnosis of gastric ulcer disease or chronic organic disability of the hands, fingers, elbows, and/or shoulders, or to provide a nexus or etiological link between in-service symptoms and any current symptomatology. See Grivois, 6 Vet. App. at 140, citing Espiritu, 2 Vet. App. at 494. Finally, the evidence of record does not show, nor is it contended by or on behalf of the veteran, that the claimed gastric ulcer disease or disability involving the hands, fingers, elbows, or shoulders are related to combat service; thus, the provisions of 38 U.S.C.A. § 1154(b) (West 1991) are not applicable in these claims. If a claim is not well grounded, the Board does not have jurisdiction to adjudicate the claim. Boeck v. Brown, 6 Vet. App. 14 (1993). A not well-grounded claim must be denied. Edenfield v. Brown, 8 Vet. App. 384 (1995). If the initial burden of presenting evidence of a well-grounded claim is not met, VA does not have a duty to assist the veteran in the development of the claim. 38 U.S.C.A. § 5107(a); Murphy, 1 Vet. App. at 81-82. The RO has advised the veteran of the evidence necessary to establish a well-grounded claim, and he has not indicated the existence or availability of any medical evidence (not already of record) that would well ground his claims of service connection for gastric ulcer disease or chronic disability of the hands, fingers, elbows, and/or shoulders (other than left ulnar styloid epiphysis). Epps v. Brown, 9 Vet. App. 341, 344 (1996), aff'd sub nom. Epps v. Gober, 126 F.3d 1464 (Fed. Cir. 1997). ORDER Service connection for gastric ulcer disease is denied. Service connection for chronic organic disability of the hands, fingers, shoulders, and elbows (with the exception of left ulnar styloid epiphysis) is denied. Service connection for left ulnar styloid epiphysis is granted. J. F. Gough Member, Board of Veterans' Appeals